The Withrow Institute for Healing Arts
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Balanced Healing Acupuncture and Wellness Camilla Schwarz, RN, M.Ac., L.Ac. Tiana Guinard, M.Ac., L.Ac.
115 Annapolis St. Annapolis, MD 21401 410-268-6733
Patient Registration Form (Please print clearly)
Name:______Date______
Address:______City______Zip______
Home Phone #______Work Phone #______
Age______Date of Birth______Cell Phone #______
Employer______Occupation______
Address______City______Zip______
Email______
How often do you check your email (circle one):
weekly every other day daily more than once a day
Do you live alone ?______
If not, with whom?
Name of Em. Contact______Phone #______
Have you been treated with Acupuncture or Chinese Medicine before?______
If yes, when and for what reason?
______
Is there someone we may thank for referring you to our practice?
______COMPREHENSIVE ACUPUNCTURE EXAMINATION NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person without your authorization.
NAME______Date______Birth Date______Height______Weight______Major Complaint(s)______Other Complaints______Date of onset (when you first noticed your problem)______Pain is: Minimal Slight Moderate Severe How long have you had this condition?______Have you had this in the past? Yes No When?______What makes it better______What makes it worse? ______Is your condition: Getting worse Constant Comes and Goes Medications/Drugs/Herbs you are currently taking:______List Surgeries/Operations you have had and dates:______Date of your last physical examination______By whom?______
MEDICAL HISTORY: (Do you have or have you ever had): Arthritis Asthma Anemia Heart trouble Cancer Diabetes Epilepsy Stroke Kidney or bladder trouble Gallstones Ulcers High blood pressure Chronic Fatigue Hepatitis Jaundice Sudden weight loss Sudden weight gain Other:______FAMILY HISTORY: (Has any member of your family had any of the above?) Yes No If yes, which member and what did they have?______
ENERGY LEVEL: High (Time of day)______ Low (Time of day)______STRESS: None Moderate Severe What causes it?______SWEATING: Night Sweats Rarely sweat Excess sweating______CIRCULATION: Feelings of Hot Cold What area?______ Bleed easily Cold limbs Other:______SKIN: Dry Itchy Moist/clammy Burning Changing moles or lumps (cysts/tumors) Boils Frequent skin rashes Acne Hair loss/thinning Dry scalp Skin puffy/wrinkled Bruises easily (black and blue spots) Hives Other:______SCARS: (List ALL scars from accidents or surgeries)______SLEEP PROBLEMS: Trouble falling asleep Trouble staying asleep Restful Excess dreaming HEAD: Headaches (what area?)______ Dizziness Memory loss Loss of balance Other:______EYES: Eye pain Dry eyes Blurred vision Darkness under eyes Other:______EARS: Poor hearing Earaches Ear discharge/infections Ringing/buzzing in ears Other:______NOSE: Frequent nose bleeds Sinus trouble Frequent colds Other:______THROAT: Sore throat Hoarseness Difficulty swallowing Jaw problems Teeth/gum problems Swollen tongue Other:______CHEST: Hard to breathe Wheezing Shortness of breath Mucus rattles when breathing Trouble breathing at night Pain/pressure in chest Palpatations Persistent cough Coughing blood Coughing phlegm Sputum color______Consistency______Other:______BLOOD PRESSURE: High Low Do not know BOWELS: Diarrhea Constipation Bloody stools Black stools Mucus in stools Hemorrhoids Lower bowel gas Stools have foul odor Colon problems Number of bowel movements a day _____ Other:______URINE: Color______Amount______ Frequent urination Daytime At night Strong smelling urine Hard to urinate Pain or burning on urinating Blood in urine Frequent infections Water retention Other:______MUSCULOSKELETAL: Pain in: Neck Shoulder Between shoulders Arms/hands Hip Knee Fingers Big toe Upper back Mid back Lower back Bones sore/painful Loss of grip Swollen knees/elbows Leg cramps at night Weakness in legs Weak ankles Stiff all over Tingling in feet Muscle spasm/cramps Loss of feeling in hands/feet Painful joints Bursitis Other:______NEUROLOGICAL: Nervousness Depressed Easily angered Easily irritated Frequent crying Worry/Anxiety Mood swings Memory confusion Poor concentration Suicidal Tremors Numbness/tingling in limbs Poor coordination Muscle weakness Feel weak and shaky Seizures Neuralgia (nerve pain) Shingles Other:______FEMALES: Pregnant? yes no Last monthly period______Last PAP test______Form of birth control: None Pill Other______Age started menstrual cycle______Age stopped______ Menstrual Pain Low backache Irregular Clotting Heavy bleeding Light scanty bleeding Color______ Water retention Mood changes Miss periods Low or no sex drive Painful breasts Hot flashes Food cravings Other:______Discharges: Yellow Thick White Odor Itching Liquid Other:______No. Pregnancies______No. Deliveries______No. Miscarriages______No. Abortions______No. Cesareans______Operations: Cervix Uterus Ovaries Other:______MALES: Low sex drive Lack of sexual drive Impotence Ejaculation causes pain Discharges Pain or burning while urinating Premature ejaculation Prostate trouble Other:______APPETITE: Excessive appetite Poor appetite Appetite keeps changing Feel tired or weak if a meal is missed Excessive thirst Never thirsty Other:______Specific food cravings? Yes No If yes, what?______Other:______DIGESTION: Stomach gas Lower bowel gas Heartburn Burning/belching Stomach pain Stomach cramps Nausea Vomiting Bad Breath Sores in mouth Weight gain Weight loss Bitter/sour taste in mouth Abdominal bloating How long after eating?______Food allergies? yes no If yes, to what?______
NUTRITION: List some of your favorite foods______
DO YOU: Skip breakfast Eat a snack Eat a hearty breakfast How many meals a day do you eat?______When is your biggest meal?______Do you eat when you are worried or rushed? yes no How often?______Do you plan your meals according to the “Four basic food groups”? yes no How many glassed of water do you drink a day?______ Filtered Bottled Do you use: Alcohol yes no Amount per week______Type______Tobacco yes no Packs per day______How many years______
DO YOU: Eat raw fruits or vegetables at least twice a day? yes no Eat green or yellow vegetables at least twice a day? yes no Eat frequently between meals? yes no Chew your food thoroughly before swallowing it? yes no Drink juice, milk or other drinks instead of water when thirsty? yes no Always add salt at the table? yes no Eat meat or dairy products 2 or more times a day? yes no Eat the same foods almost every day? yes no Eat when you are not hungry? yes no Eat until you are full? yes no Occasionally go on a “crash” diet? yes no
Patient’s Signature______